Navigating the Landscape of Query Compliance: AHIMA and ACDIS 2022 Guideline Updates

AHIMA and ACDIS published the updated guidelines for Guidelines for Achieving a Compliant Query Practice—2022 Update this year.  How are you doing with the new guidelines? Your goal and our goal is to improve clinical documentation to serve the patient.  Other groups also pay close attention to these updated guidelines. Insurance companies are using the changes in their claims review process and denying inpatient payment when they interpret a query to be non-compliant. This blog will alert you to what we are seeing and this in turn may help you with the queries you generate in your daily processes. 

 

How are these documents used? 

The obvious: The updated guidelines are to help Clinical Documentation Specialists (CDS) and coders as well as providers that generate the documentation to create a health record that accurately and truthfully tells each patient’s health care story or “the clinical truth.” The other entities that review the health record are payors, auditors, and compliance agencies and their review of the health record is primarily for the purposes of payment, or denial of payment, and to audit compliance with their regulations.  

The guidelines are not regulatory documents. “The practice brief’s purpose is to establish and support industry-wide best practices for the clinical documentation query process (documentation clarification).” So, while not a regulatory document, it is used by regulators and payers as the reference for “industry-wide best practices.” 

Remember the updated guidelines are used for different purposes, depending on who reviews the health record.  

 

What needs to be in a query? 

A query is a question posed to a provider. The purpose of a query is to bring more clarity, when possible, about the clinical status of a patient. The query response will most often lead to a diagnosis that can be coded. The Practice Brief provides the detail needed to create compliant queries in the inpatient and outpatient settings.  

Through our work assisting our clients with payment denials, we see the reasons insurance companies deny payment of claims. And we are seeing denials based on insurance companies’ interpretation of the content of the Practice Brief.  As mentioned above, insurance companies may use the guidelines because they are the industry standard. In the appendix of the Practice Brief the query examples are provided and all include dates and a reference to a specific chart location like H&P or progress note.  This is useful information for a provider responding to a query. Insurance company reviewers are denying payment when a query does not include the dates and health record location of the information that is referenced in the query. A technical denial, but a denial.  

 

Denial Examples

One example of a denial of payment with a payor using the Practice Brief: “The query is non-compliant because the source of the clinical indicators as a citation from the medical record was not provided.”  

Here’s another denial example based on the payors evaluation of the query: 

A patient is admitted with an acute COVID-19 infection. The patient’s oxygen saturation is 88% on room air. With 4 liters of binasal oxygen, the oxygen saturation improved. The query to the provider asks if sepsis is present due to the COVID-19 infection. The provider’s institution validates sepsis using the Sepsis-3 definition and the payor also uses the Sepsis-3 definition. The payor denied payment on the claim because in their opinion the query did not offer “all” clinically relevant options. The denial is based on not offering acute respiratory failure due to COPD exacerbation as a query option. The query provides two options besides sepsis. One is localized infection without sepsis and the second is an option of Other. This provides the provider the opportunity to document if the hypoxia, generating the SOFA points, is not related to sepsis. In this case, the word “all” relevant answer options can be misused by the payor in denying claims payment.  Queries are generated in unique clinical environments and have evolved to be effective in those unique environments. This is an example of the payor, not the hospital’s CDS, deciding what is clinically relevant. 

 

Summary 

The query process is essential to ensure meaningful clinical information is captured in a patient’s health record.  Stay-tuned for our next blog as we review the AHIMA Practice Brief Clinical Validation (2023) Update.